Intubation & Airway Management

Patients With or Under Investigation for COVID-19

Background

  • Transmission of COVID-19 is thought to primarily occur via droplet spread.

  • However, certain events can result in the generation of aerosols composed of smaller virus-containing particles that can remain in the air for longer periods and can travel greater distances. These events put HCWs at greater risk. 

  • Aerosol generating events include: non-invasive positive pressure ventilation (NIPPV), bag-valve mask ventilation, humidified high flow nasal cannula (HFNC), tracheal suctioning through an open system, delivery of nebulized medications via a simple face mask, intubation, bronchoscopy, mini-BAL collection of lower respiratory specimens, sputum induction, tracheal extubation, and cardiopulmonary resuscitation (CPR)

  • The airway management of respiratory failure in COVID-19 patients and PUIs should prioritize early and controlled intubation if the patient has clinical evidence of progressive hypoxemia in order to avoid aerosol generating procedures in an uncontrolled setting. 

  • Non-invasive ventilation and bag-mask ventilation should not be used under normal circumstances 

 

Indications

  • Acute hypoxemic respiratory failure requiring > 6 L/min nasal cannula and not rapidly improving on NRB or HFNC

  • Any other conventional indications for endotracheal intubation

 

PPE

  • Intubation is an aerosol-generative procedure. Full ACE PPE is required for the intubator

 

Equipment

  • COVID-19 Airway Box (see Photo 1)

    • Size 7.5 and 8 ETT

    • Size 4 and 5 LMA

    • Guedel oral airway (2 sizes)

    • Portable videolaryngoscopy unit (Glidescope) with small and large disposable Glidescope sheaths

    • Disposable flexible bronchoscope

    • Ambu-bag-ventilator tubing that has been previously connected together rather than individual components separated (see Photo 2). This should include in-line suction, EtCO2 monitor, and Heat Moisture Exchange (HME)/bacterial/viral filter

    • Lubricant

    • Bougie

    • Kelley clamp

    • 10 cc syringe

    • ETT holder
       

  • Other Equipment

    • Yankhauer suction

    • Sump orogastric (OG) tube or NG/Dobhoff tube

    • Ventilator

 

  • PPE

    • ACE PPE all HCWs (see PPE protocols for donning and doffing)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Preparation, Location, and Timing

  • If a patient has an increasing oxygen requirement to 6 liters nasal cannula, the patient should be placed in a negative pressure room if available 

  • The managing ICU attending should be contacted and assess the patient and airway.  

  • If there is a concern for a difficult airway, the on-call anesthesia attending should also be contacted.  

  • In urgent situations if the ICU and anesthesia attendings are not available, an OORAM-privileged ED provider may be available to assist. 

  • In emergent situations (Cardiac arrest), respiratory therapy can manage airway. 

 

Assemble Team

  • In room: OORAM privileged provider, two ICU nurses, at least one RT

  • Out of room: A runner in DCE[NM2]  PPE

  • Minimize number of healthcare workers 

 

Pre-Check & Pre-Brief

    • Equipment Check

      • Ensure IV access (discuss outside room)

      • Ensure working suction (discuss outside room)

      • Ensure that all airway supplies are assembled and brought into room. See accompanying equipment checklist above. 

      • Endure that Glidescope is charged and operational. Ensure that disposable bronchoscope is on the cart.

      • Order drugs needed for RSI, post-intubation sedation gtts, and norepinephrine gtts so that they can be prepared by pharmacy.

    • Pre-oxygenation 

      • Determine optimal pre-oxygenation strategy 

      • Avoid high flow nasal cannula and NIPPV. Use 6 L/min NC with surgical mask on patient or NRB

    • Intubation Plan

      • Plan A: Rapid Sequence Intubation with video laryngoscopy

      • Plan B: Fiberoptic intubation using ETT loaded over disposable bronchoscope

      • Plan C: Place an LMA and bag mask ventilate through LMA until paralysis wears off.

        • Medication Plan 

          • Place orders for medications and ventilator

            • Induction agent: Etomidate (0.3 mg/kg) or Propofol push (1 mg/kg)

            • Paralytic agent: High dose Rocuronium (1.2 mg/kg) or Succinylcholine (1.5-2.0 mg/kg) 

            • Sedation: Fentanyl, Remifentanil, Propofol, and/or Midazolam IV drip

            • IVF: Lactated Ringers bolus 

            • Hemodynamic: Norepinephrine IV drip

      • Key considerations

        • Induction doses of ketamine may exacerbate the already copious bronchorrhea that accompanies may cases of COVID-19 pneumonia

        • Avoid escalated push dosing of Fentanyl/Midazolam. This contradicts the goal of RSI, which is to secure an immediate airway without need for BVM.

 

Organize 

  • Ensure needed personnel, equipment, drugs are in room 

  • Door closed 

  • Set up viral filter and EtCO2 in line on BVM and ventilator circuit 

  • Set up closed suctioning system with tight seal on cannister 

  • BP cuff set for q2-3 min on opposite arm as pulse ox. SpO2 sound can be turned on if desired

  • Contact tele-ICU of impending intubation so they can assist as needed with orders or coordination of care 

 

Optimize 

  • Pre-oxygenate using pre-determined strategy. Consider apneic oxygenation with NRB or HFNC

  • Correct hypotension or acidosis as needed 

  • Position patient, raise bed to best height for provider intubating, use towel rolls to create neck extension

  • If patient is agitated, consider adjunctive medications that preserve respiratory drive (ketamine, dexmedetomidine, low dose midazolam)  

Induce and Intubate 

  • Perform time out 

  • Administer RSI medications and wait 1 minute. Do not bag mask during apneic period unless life threatening hypoxemia. 

  • Turn off HFNC or NRB (if applicable), then take off patient’s surgical mask

  • Intubate

    • Single intubator preferred. With Glidescope, this requires the intubator to eject the rigid stylet with their dominant (intubating) thumb and inflate the cuff. These may be new skills, and should be practiced on a mannequin if possible. 

  • Ensure cuff inflation

  • Connect to ventilator with an in-line viral filter and EtCO2 monitor (already in place) and ensure tight seal. 

    • If patient requires BV-ETT prior to connecting to vent, follow these steps: Clamp ETT → Remove Ambu bag → Connect ETT to vent → Unclamp ETT 

 

Post-Check and Debrief

  • ET Tube Assessment

  • Confirm EtCO2 waveform. Look for chest rise. Listen for bilateral breath sounds. Secure ETT and mark position at teeth

  • Avoid disconnecting from ventilator. If disconnection is necessary, place vent in standby mode and clamp ETT prior to disconnecting 

  • If patient develops signs of an air leak, this should be treated as a possible aerosol generating event until the air leak is resolved

 

Post-Intubation Physiologic Optimization 

  • Correct periprocedural hypotension (e.g. with norepinephrine infusion) 

  • Start analgesia/sedation (patient will be paralyzed for 6-10 minutes after succinylcholine and 30-70 minutes after rocuronium)

  • Send ABG 

  • Place HOB at 30 degrees 

  • Initiate lung-protective ARDS ventilation (See General Mechanical Ventilation protocol)

 

Other procedures 

  • To reduce PPE used and to minimize the need for multiple radiology procedures, the MICU providers should generally proactively place additional invasive lines even if the patient is not currently hypotensive 

    • Central Venous Catheter  

    • Arterial Line 

    • Nursing should place OG/NG/DH tube and Foley catheter 

 

Ensure Everyone's Safety

  • Place Glidescope blade and any soiled equipment in red biohazard bag. 

  • Any unused equipment in the room can be considered to be contaminated and should not be reused 

  • Wipe down Glidescope and ultrasound machine with disinfectant. Push both out of room with foot 

  • Doffing PPE: Personnel should inspect each other’s technique while donning PPE to ensure proper technique 

  • Wipe down glidescope and ultrasound machine again with disinfectant 

  • If not already done, order chest and abdominal xrays. Place orders for mechanical ventilation protocol.

  • Communicate with RT strategies for ventilator management (See General Mechanical Ventilation protocol) so as to minimize unnecessary patient contact.

Example of COVID-19 airway box (courtesy of Univ. Michigan)

Example of pre-connected ventilator tubing

Information presented on this website does not reflect the views or positions of the US Veterans Health Administration, Emory Healthcare, or its affiliated institutions. This is a rapidly evolving field. As such. the content on this site is being updated daily and protocols will be updated in real time.  The purpose of this site is to provide a centralized resource for ICU topics and protocols to promote the well-being of hospitalized or critically ill patients suffering from COVID-19.  Defer to your institutional guidelines for all clinical practice decisions.

 

© 2020  Victor Tseng, MD